ANNAPOLIS – Maryland hospitals are increasing staff training and drills to prevent operating room blazes, after a health care commission issued a warning about underreported surgical fires.
Surgical fires, which can ignite from electrosurgical equipment coming in contact with alcohol and an oxygen-enriched room, can cause patients to lose taste or smell, damage eyes, be disfigured or even die.
The alert issued in June by the Joint Commission for the Accreditation of Health Care Organizations noted the 100 fires reported nationally every year are “significantly underreported.”
There is no national- or state-mandated surgical fire reporting or prevention system, but in Maryland, hospitals realize the need for increased prevention.
The alert was issued to all 17,000 organizations the commission accredits. Recommendations included training staff members, developing and testing fire responses and reporting any fires
“Hospitals have heard about it now. The Joint Commission has made it a viable topic of safety concern,” said Mark Bruley, vice president of accident and forensic investigation for ECRI, a nonprofit patient safety organization.
To prevent fires, Bruly said, hospitals must be willing to participate in training, and surgeons, anesthesiologists and operating room nurses must cooperate. Once all parties are involved, he said, workshops, fire drills and procedures can be established.
“The real issue is communication,” he said, noting that all surgical fires can be prevented.
The alert has been a reminder for some Maryland hospitals with procedures already in place, but it’s been a wake-up call for others.
Johns Hopkins and Baltimore Memorial Hospital will review their established safety procedures in light of the warning.
“We have not had any surgical fires, but we did get the alert,” said Kim Lovett, spokeswoman for Upper Chesapeake Health. “We will be implementing the prevention plan in both hospitals.”
Upper Chesapeake Health, which includes Upper Chesapeake Medical Center and Harford Memorial Hospital, held a surgical fire drill in October.
“The drill helped the staff better find their role in responding,” Lovett said. The nursing team, surgeons, anesthesiologists and safety officers all participated in what will be a twice-yearly drill.
The hospital also held in-service training on the preparation of patients for surgery, flammable chemicals used in the operating room and evacuation procedures.
Electrosurgical equipment, alcohol-based prepping agents and ointments are usually involved in creating the blaze.
“The basic elements of a fire are always present during surgery and a misstep in procedure or a momentary lapse of caution can quickly result in a catastrophe,” said Bruley in the alert.
Electrosurgical equipment or lasers are the most common ignition sources for surgical fires and 62 percent of the fires occur in a patient’s airway, head or face. An oxygen-rich atmosphere was a contributing factor in 74 percent of the cases, according to the report.
“Just because you’re doing something hazardous doesn’t mean you can continue doing it,” said Bruley. “Ignorance of a hazard within a profession is a poor excuse.”